Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 19003 | Noridian Healthcare Solutions, LLC | DME MAC | AK AS AZ CA CNMI GU HI IA ID KS MO MT ND NE NV OR SD UT WA WY |
| 18003 | CGS Administrators, LLC | DME MAC | AL AR CO FL GA LA MS NC NM OK PR SC TN TX VA VI WV |
| 17013 | CGS Administrators, LLC | DME MAC | IL IN KY MI MN OH WI |
| 16013 | Noridian Healthcare Solutions, LLC | DME MAC | CT DC DE MA MD ME NH NJ NY PA RI VT |
Procedure codes named in the LCD
L5000 (Partial Foot, Shoe Insert With Longitudinal Arch, Toe Filler), L5010 (Partial Foot, Molded Socket, Ankle Height, With Toe Filler), L5020 (Partial Foot, Molded Socket, Tibial Tubercle Height, With Toe Filler), L5050 (Ankle, Symes, Molded Socket, Sach Foot), L5060 (Ankle, Symes, Metal Frame, Molded Leather Socket, Articulated Ankle/Foot), L5100 (Below Knee, Molded Socket, Shin, Sach Foot), L5105 (Below Knee, Plastic Socket, Joints And Thigh Lacer, Sach Foot), L5150 (Knee Disarticulation (Or Through Knee), Molded Socket, External Knee Joints, Shin, Sach Foot), L5160 (Knee Disarticulation (Or Through Knee), Molded Socket, Bent Knee Configuration, External Knee Joints, Shin, Sach Foot), L5200 (Above Knee, Molded Socket, Single Axis Constant Friction Knee, Shin, Sach Foot), L5210 (Above Knee, Short Prosthesis, No Knee Joint ('Stubbies'), With Foot Blocks, No Ankle Joints, Each), L5220 (Above Knee, Short Prosthesis, No Knee Joint ('Stubbies'), With Articulated Ankle/Foot, Dynamically Aligned, Each), L5230 (Above Knee, For Proximal Femoral Focal Deficiency, Constant Friction Knee, Shin, Sach Foot), L5250 (Hip Disarticulation, Canadian Type; Molded Socket, Hip Joint, Single Axis Constant Friction Knee, Shin, Sach Foot), L5270 (Hip Disarticulation, Tilt Table Type; Molded Socket, Locking Hip Joint, Single Axis Constant Friction Knee, Shin, Sach Foot), L5280 (Hemipelvectomy, Canadian Type; Molded Socket, Hip Joint, Single Axis Constant Friction Knee, Shin, Sach Foot), L5301 (Below Knee, Molded Socket, Shin, Sach Foot, Endoskeletal System), L5312 (Knee Disarticulation (Or Through Knee), Molded Socket, Single Axis Knee, Pylon, Sach Foot, Endoskeletal System), L5321 (Above Knee, Molded Socket, Open End, Sach Foot, Endoskeletal System, Single Axis Knee), L5331 (Hip Disarticulation, Canadian Type, Molded Socket, Endoskeletal System, Hip Joint, Single Axis Knee, Sach Foot), L5341 (Hemipelvectomy, Canadian Type, Molded Socket, Endoskeletal System, Hip Joint, Single Axis Knee, Sach Foot), L5400 (Immediate Post Surgical Or Early Fitting, Application Of Initial Rigid Dressing, Including Fitting, Alignment, Suspension, And One Cast Change, Below Knee), L5410 (Immediate Post Surgical Or Early Fitting, Application Of Initial Rigid Dressing, Including Fitting, Alignment And Suspension, Below Knee, Each Additional Cast Change And Realignment), L5420 (Immediate Post Surgical Or Early Fitting, Application Of Initial Rigid Dressing, Including Fitting, Alignment And Suspension And One Cast Change 'Ak' Or Knee Disarticulation), L5430 (Immediate Post Surgical Or Early Fitting, Application Of Initial Rigid Dressing, Incl. Fitting, Alignment And Supension, 'Ak' Or Knee Disarticulation, Each Additional Cast Change And Realignment), L5450 (Immediate Post Surgical Or Early Fitting, Application Of Non-Weight Bearing Rigid Dressing, Below Knee), L5460 (Immediate Post Surgical Or Early Fitting, Application Of Non-Weight Bearing Rigid Dressing, Above Knee), L5500 (Initial, Below Knee 'Ptb' Type Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Plaster Socket, Direct Formed), L5505 (Initial, Above Knee - Knee Disarticulation, Ischial Level Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Plaster Socket, Direct Formed), L5510 (Preparatory, Below Knee 'Ptb' Type Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Plaster Socket, Molded To Model), L5520 (Preparatory, Below Knee 'Ptb' Type Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Thermoplastic Or Equal, Direct Formed), L5530 (Preparatory, Below Knee 'Ptb' Type Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Thermoplastic Or Equal, Molded To Model), L5535 (Preparatory, Below Knee 'Ptb' Type Socket, Non-Alignable System, No Cover, Sach Foot, Prefabricated, Adjustable Open End Socket), L5540 (Preparatory, Below Knee 'Ptb' Type Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Laminated Socket, Molded To Model), L5560 (Preparatory, Above Knee- Knee Disarticulation, Ischial Level Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Plaster Socket, Molded To Model), L5570 (Preparatory, Above Knee - Knee Disarticulation, Ischial Level Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Thermoplastic Or Equal, Direct Formed), L5580 (Preparatory, Above Knee - Knee Disarticulation Ischial Level Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Thermoplastic Or Equal, Molded To Model), L5585 (Preparatory, Above Knee - Knee Disarticulation, Ischial Level Socket, Non-Alignable System, Pylon, No Cover, Sach Foot, Prefabricated Adjustable Open End Socket), L5590 (Preparatory, Above Knee - Knee Disarticulation Ischial Level Socket, Non-Alignable System, Pylon No Cover, Sach Foot, Laminated Socket, Molded To Model), L5595 (Preparatory, Hip Disarticulation-Hemipelvectomy, Pylon, No Cover, Sach Foot, Thermoplastic Or Equal, Molded To Patient Model), L5600 (Preparatory, Hip Disarticulation-Hemipelvectomy, Pylon, No Cover, Sach Foot, Laminated Socket, Molded To Patient Model), L5610 (Addition To Lower Extremity, Endoskeletal System, Above Knee, Hydracadence System), L5611 (Addition To Lower Extremity, Endoskeletal System, Above Knee - Knee Disarticulation, 4 Bar Linkage, With Friction Swing Phase Control), L5613 (Addition To Lower Extremity, Endoskeletal System, Above Knee-Knee Disarticulation, 4 Bar Linkage, With Hydraulic Swing Phase Control), L5614 (Addition To Lower Extremity, Exoskeletal System, Above Knee-Knee Disarticulation, 4 Bar Linkage, With Pneumatic Swing Phase Control), L5615 (Addition, Endoskeletal Knee-Shin System, 4 Bar Linkage Or Multiaxial, Fluid Swing And Stance Phase Control), L5616 (Addition To Lower Extremity, Endoskeletal System, Above Knee, Universal Multiplex System, Friction Swing Phase Control), L5617 (Addition To Lower Extremity, Quick Change Self-Aligning Unit, Above Knee Or Below Knee, Each), L5618 (Addition To Lower Extremity, Test Socket, Symes), L5620 (Addition To Lower Extremity, Test Socket, Below Knee), L5622 (Addition To Lower Extremity, Test Socket, Knee Disarticulation), L5624 (Addition To Lower Extremity, Test Socket, Above Knee), L5626 (Addition To Lower Extremity, Test Socket, Hip Disarticulation), L5628 (Addition To Lower Extremity, Test Socket, Hemipelvectomy), L5629 (Addition To Lower Extremity, Below Knee, Acrylic Socket), L5630 (Addition To Lower Extremity, Symes Type, Expandable Wall Socket), L5631 (Addition To Lower Extremity, Above Knee Or Knee Disarticulation, Acrylic Socket), L5632 (Addition To Lower Extremity, Symes Type, 'Ptb' Brim Design Socket), L5634 (Addition To Lower Extremity, Symes Type, Posterior Opening (Canadian) Socket), L5636 (Addition To Lower Extremity, Symes Type, Medial Opening Socket), L5637 (Addition To Lower Extremity, Below Knee, Total Contact), L5638 (Addition To Lower Extremity, Below Knee, Leather Socket), L5639 (Addition To Lower Extremity, Below Knee, Wood Socket), L5640 (Addition To Lower Extremity, Knee Disarticulation, Leather Socket), L5642 (Addition To Lower Extremity, Above Knee, Leather Socket), L5643 (Addition To Lower Extremity, Hip Disarticulation, Flexible Inner Socket, External Frame), L5644 (Addition To Lower Extremity, Above Knee, Wood Socket), L5645 (Addition To Lower Extremity, Below Knee, Flexible Inner Socket, External Frame), L5646 (Addition To Lower Extremity, Below Knee, Air, Fluid, Gel Or Equal, Cushion Socket), L5647 (Addition To Lower Extremity, Below Knee Suction Socket), L5648 (Addition To Lower Extremity, Above Knee, Air, Fluid, Gel Or Equal, Cushion Socket), L5649 (Addition To Lower Extremity, Ischial Containment/Narrow M-L Socket), L5650 (Additions To Lower Extremity, Total Contact, Above Knee Or Knee Disarticulation Socket), L5651 (Addition To Lower Extremity, Above Knee, Flexible Inner Socket, External Frame), L5652 (Addition To Lower Extremity, Suction Suspension, Above Knee Or Knee Disarticulation Socket), L5653 (Addition To Lower Extremity, Knee Disarticulation, Expandable Wall Socket), L5654 (Addition To Lower Extremity, Socket Insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote Or Equal)), L5655 (Addition To Lower Extremity, Socket Insert, Below Knee (Kemblo, Pelite, Aliplast, Plastazote Or Equal)), L5656 (Addition To Lower Extremity, Socket Insert, Knee Disarticulation (Kemblo, Pelite, Aliplast, Plastazote Or Equal)), L5657 (Addition To Lower Extremity Prosthesis, Manual/Automated Adjustable Air, Fluid, Gel Or Equal Socket Insert For Limb Volume Management, Any Materials), L5658 (Addition To Lower Extremity, Socket Insert, Above Knee (Kemblo, Pelite, Aliplast, Plastazote Or Equal)), L5661 (Addition To Lower Extremity, Socket Insert, Multi-Durometer Symes), L5665 (Addition To Lower Extremity, Socket Insert, Multi-Durometer, Below Knee), L5666 (Addition To Lower Extremity, Below Knee, Cuff Suspension), L5668 (Addition To Lower Extremity, Below Knee, Molded Distal Cushion), L5670 (Addition To Lower Extremity, Below Knee, Molded Supracondylar Suspension ('Pts' Or Similar)), L5671 (Addition To Lower Extremity, Below Knee / Above Knee Suspension Locking Mechanism (Shuttle, Lanyard Or Equal), Excludes Socket Insert), L5672 (Addition To Lower Extremity, Below Knee, Removable Medial Brim Suspension), L5673 (Addition To Lower Extremity, Below Knee/Above Knee, Custom Fabricated From Existing Mold Or Prefabricated, Socket Insert, Silicone Gel, Elastomeric, Or Equal, With Or Without Perforations, With Or Without Breathable Material, For Use With Locking Mechanism), L5676 (Additions To Lower Extremity, Below Knee, Knee Joints, Single Axis, Pair), L5677 (Additions To Lower Extremity, Below Knee, Knee Joints, Polycentric, Pair), L5678 (Additions To Lower Extremity, Below Knee, Joint Covers, Pair), L5679 (Addition To Lower Extremity, Below Knee/Above Knee, Custom Fabricated From Existing Mold Or Prefabricated, Socket Insert, Silicone Gel, Elastomeric, Or Equal, With Or Without Perforations, With Or Without Breathable Material, Not For Use With Locking Mechanism), L5680 (Addition To Lower Extremity, Below Knee, Thigh Lacer, Nonmolded), L5681 (Addition To Lower Extremity, Below Knee/Above Knee, Custom Fabricated Socket Insert For Congenital Or Atypical Traumatic Amputee, Silicone Gel, Elastomeric Or Equal, For Use With Or Without Locking Mechanism, Initial Only (For Other Than Initial, Use Code L5673 Or L5679)), L5682 (Addition To Lower Extremity, Below Knee, Thigh Lacer, Gluteal/Ischial, Molded), L5683 (Addition To Lower Extremity, Below Knee/Above Knee, Custom Fabricated Socket Insert For Other Than Congenital Or Atypical Traumatic Amputee, Silicone Gel, Elastomeric Or Equal, For Use With Or Without Locking Mechanism, Initial Only (For Other Than Initial, Use Code L5673 Or L5679)), L5684 (Addition To Lower Extremity, Below Knee, Fork Strap), L5685 (Addition To Lower Extremity Prosthesis, Below Knee, Suspension/Sealing Sleeve, With Or Without Valve, Any Material, Each), L5686 (Addition To Lower Extremity, Below Knee, Back Check (Extension Control)), L5688 (Addition To Lower Extremity, Below Knee, Waist Belt, Webbing), L5690 (Addition To Lower Extremity, Below Knee, Waist Belt, Padded And Lined), L5692 (Addition To Lower Extremity, Above Knee, Pelvic Control Belt, Light), L5694 (Addition To Lower Extremity, Above Knee, Pelvic Control Belt, Padded And Lined), L5695 (Addition To Lower Extremity, Above Knee, Pelvic Control, Sleeve Suspension, Neoprene Or Equal, Each), L5696 (Addition To Lower Extremity, Above Knee Or Knee Disarticulation, Pelvic Joint), L5697 (Addition To Lower Extremity, Above Knee Or Knee Disarticulation, Pelvic Band), L5698 (Addition To Lower Extremity, Above Knee Or Knee Disarticulation, Silesian Bandage), L5699 (All Lower Extremity Prostheses, Shoulder Harness), L5700 (Replacement, Socket, Below Knee, Molded To Patient Model), L5701 (Replacement, Socket, Above Knee/Knee Disarticulation, Including Attachment Plate, Molded To Patient Model), L5702 (Replacement, Socket, Hip Disarticulation, Including Hip Joint, Molded To Patient Model), L5703 (Ankle, Symes, Molded To Patient Model, Socket Without Solid Ankle Cushion Heel (Sach) Foot, Replacement Only), L5704 (Custom Shaped Protective Cover, Below Knee), L5705 (Custom Shaped Protective Cover, Above Knee), L5706 (Custom Shaped Protective Cover, Knee Disarticulation), L5707 (Custom Shaped Protective Cover, Hip Disarticulation), L5710 (Addition, Exoskeletal Knee-Shin System, Single Axis, Manual Lock), L5711 (Additions Exoskeletal Knee-Shin System, Single Axis, Manual Lock, Ultra-Light Material), L5712 (Addition, Exoskeletal Knee-Shin System, Single Axis, Friction Swing And Stance Phase Control (Safety Knee)), L5714 (Addition, Exoskeletal Knee-Shin System, Single Axis, Variable Friction Swing Phase Control), L5716 (Addition, Exoskeletal Knee-Shin System, Polycentric, Mechanical Stance Phase Lock), L5718 (Addition, Exoskeletal Knee-Shin System, Polycentric, Friction Swing And Stance Phase Control), L5722 (Addition, Exoskeletal Knee-Shin System, Single Axis, Pneumatic Swing, Friction Stance Phase Control), L5724 (Addition, Exoskeletal Knee-Shin System, Single Axis, Fluid Swing Phase Control), L5726 (Addition, Exoskeletal Knee-Shin System, Single Axis, External Joints Fluid Swing Phase Control), L5728 (Addition, Exoskeletal Knee-Shin System, Single Axis, Fluid Swing And Stance Phase Control), L5780 (Addition, Exoskeletal Knee-Shin System, Single Axis, Pneumatic/Hydra Pneumatic Swing Phase Control), L5781 (Addition To Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume Management And Moisture Evacuation System), L5782 (Addition To Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume Management And Moisture Evacuation System, Heavy Duty), L5783 (Addition To Lower Extremity, User Adjustable, Mechanical, Residual Limb Volume Management System (With Or Without Lamination Kit)), L5785 (Addition, Exoskeletal System, Below Knee, Ultra-Light Material (Titanium, Carbon Fiber Or Equal)), L5790 (Addition, Exoskeletal System, Above Knee, Ultra-Light Material (Titanium, Carbon Fiber Or Equal)), L5795 (Addition, Exoskeletal System, Hip Disarticulation, Ultra-Light Material (Titanium, Carbon Fiber Or Equal)), L5810 (Addition, Endoskeletal Knee-Shin System, Single Axis, Manual Lock), L5811 (Addition, Endoskeletal Knee-Shin System, Single Axis, Manual Lock, Ultra-Light Material), L5812 (Addition, Endoskeletal Knee-Shin System, Single Axis, Friction Swing And Stance Phase Control (Safety Knee)), L5814 (Addition, Endoskeletal Knee-Shin System, Polycentric, Hydraulic Swing Phase Control, Mechanical Stance Phase Lock), L5816 (Addition, Endoskeletal Knee-Shin System, Polycentric, Mechanical Stance Phase Lock), L5818 (Addition, Endoskeletal Knee-Shin System, Polycentric, Friction Swing, And Stance Phase Control), L5822 (Addition, Endoskeletal Knee-Shin System, Single Axis, Pneumatic Swing, Friction Stance Phase Control), L5824 (Addition, Endoskeletal Knee-Shin System, Single Axis, Fluid Swing Phase Control), L5826 (Addition, Endoskeletal Knee-Shin System, Single Axis, Hydraulic Swing Phase Control, With Miniature High Activity Frame), L5827 (Endoskeletal Knee-Shin System, Single Axis, Electromechanical Swing And Stance Phase Control, With Or Without Shock Absorption And Stance Extension Damping), L5828 (Addition, Endoskeletal Knee-Shin System, Single Axis, Fluid Swing And Stance Phase Control), L5830 (Addition, Endoskeletal Knee-Shin System, Single Axis, Pneumatic/ Swing Phase Control), L5840 (Addition, Endoskeletal Knee/Shin System, 4-Bar Linkage Or Multiaxial, Pneumatic Swing Phase Control), L5841 (Addition, Endoskeletal Knee-Shin System, Polycentric, Pneumatic Swing, And Stance Phase Control), L5845 (Addition, Endoskeletal, Knee-Shin System, Stance Flexion Feature, Adjustable), L5848 (Addition To Endoskeletal Knee-Shin System, Fluid Stance Extension, Dampening Feature, With Or Without Adjustability), L5850 (Addition, Endoskeletal System, Above Knee Or Hip Disarticulation, Knee Extension Assist), L5855 (Addition, Endoskeletal System, Hip Disarticulation, Mechanical Hip Extension Assist), L5856 (Addition To Lower Extremity Prosthesis, Endoskeletal Knee-Shin System, Microprocessor Control Feature, Swing And Stance Phase, Includes Electronic Sensor(S), Any Type), L5857 (Addition To Lower Extremity Prosthesis, Endoskeletal Knee-Shin System, Microprocessor Control Feature, Swing Phase Only, Includes Electronic Sensor(S), Any Type), L5858 (Addition To Lower Extremity Prosthesis, Endoskeletal Knee Shin System, Microprocessor Control Feature, Stance Phase Only, Includes Electronic Sensor(S), Any Type), L5859 (Addition To Lower Extremity Prosthesis, Endoskeletal Knee-Shin System, Powered And Programmable Flexion/Extension Assist Control, Includes Any Type Motor(S)), L5910 (Addition, Endoskeletal System, Below Knee, Alignable System), L5920 (Addition, Endoskeletal System, Above Knee Or Hip Disarticulation, Alignable System), L5925 (Addition, Endoskeletal System, Above Knee, Knee Disarticulation Or Hip Disarticulation, Manual Lock), L5926 (Addition To Lower Extremity Prosthesis, Endoskeletal, Knee Disarticulation, Above Knee, Hip Disarticulation, Positional Rotation Unit, Any Type), L5930 (Addition, Endoskeletal System, High Activity Knee Control Frame), L5940 (Addition, Endoskeletal System, Below Knee, Ultra-Light Material (Titanium, Carbon Fiber Or Equal)), L5950 (Addition, Endoskeletal System, Above Knee, Ultra-Light Material (Titanium, Carbon Fiber Or Equal)), L5960 (Addition, Endoskeletal System, Hip Disarticulation, Ultra-Light Material (Titanium, Carbon Fiber Or Equal)), L5961 (Addition, Endoskeletal System, Polycentric Hip Joint, Pneumatic Or Hydraulic Control, Rotation Control, With Or Without Flexion And/Or Extension Control), L5962 (Addition, Endoskeletal System, Below Knee, Flexible Protective Outer Surface Covering System), L5964 (Addition, Endoskeletal System, Above Knee, Flexible Protective Outer Surface Covering System), L5966 (Addition, Endoskeletal System, Hip Disarticulation, Flexible Protective Outer Surface Covering System), L5968 (Addition To Lower Limb Prosthesis, Multiaxial Ankle With Swing Phase Active Dorsiflexion Feature), L5969 (Addition, Endoskeletal Ankle-Foot Or Ankle System, Power Assist, Includes Any Type Motor(S)), L5970 (All Lower Extremity Prostheses, Foot, External Keel, Sach Foot), L5971 (All Lower Extremity Prosthesis, Solid Ankle Cushion Heel (Sach) Foot, Replacement Only), L5972 (All Lower Extremity Prostheses, Foot, Flexible Keel), L5973 (Endoskeletal Ankle Foot System, Microprocessor Controlled Feature, Dorsiflexion And/Or Plantar Flexion Control, Includes Power Source), L5974 (All Lower Extremity Prostheses, Foot, Single Axis Ankle/Foot), L5975 (All Lower Extremity Prosthesis, Combination Single Axis Ankle And Flexible Keel Foot), L5976 (All Lower Extremity Prostheses, Energy Storing Foot (Seattle Carbon Copy Ii Or Equal)), L5978 (All Lower Extremity Prostheses, Foot, Multiaxial Ankle/Foot), L5979 (All Lower Extremity Prosthesis, Multi-Axial Ankle, Dynamic Response Foot, One Piece System), L5980 (All Lower Extremity Prostheses, Flex Foot System), L5981 (All Lower Extremity Prostheses, Flex-Walk System Or Equal), L5982 (All Exoskeletal Lower Extremity Prostheses, Axial Rotation Unit), L5984 (All Endoskeletal Lower Extremity Prosthesis, Axial Rotation Unit, With Or Without Adjustability), L5985 (All Endoskeletal Lower Extremity Prostheses, Dynamic Prosthetic Pylon), L5986 (All Lower Extremity Prostheses, Multi-Axial Rotation Unit ('Mcp' Or Equal)), L5987 (All Lower Extremity Prosthesis, Shank Foot System With Vertical Loading Pylon), L5988 (Addition To Lower Limb Prosthesis, Vertical Shock Reducing Pylon Feature), L5990 (Addition To Lower Extremity Prosthesis, User Adjustable Heel Height), L5991 (Addition To Lower Extremity Prostheses, Osseointegrated External Prosthetic Connector), L5992 (All Lower Extremity Prosthesis, Foot Shell For Modular Foot/Non-Solid Ankle Cushion Heel (Sach) Replacement Only), L5999 (Lower Extremity Prosthesis, Not Otherwise Specified), L7367 (Lithium Ion Battery, Rechargeable, Replacement), L7368 (Lithium Ion Battery Charger, Replacement Only), L7510 (Repair Of Prosthetic Device, Repair Or Replace Minor Parts), L7520 (Repair Prosthetic Device, Labor Component, Per 15 Minutes), L7600 (Prosthetic Donning Sleeve, Any Material, Each), L7700 (Gasket Or Seal, For Use With Prosthetic Socket Insert, Any Type, Each), L8400 (Prosthetic Sheath, Below Knee, Each), L8410 (Prosthetic Sheath, Above Knee, Each), L8417 (Prosthetic Sheath/Sock, Including A Gel Cushion Layer, Below Knee Or Above Knee, Each), L8420 (Prosthetic Sock, Multiple Ply, Below Knee, Each), L8430 (Prosthetic Sock, Multiple Ply, Above Knee, Each), L8440 (Prosthetic Shrinker, Below Knee, Each), L8460 (Prosthetic Shrinker, Above Knee, Each), L8470 (Prosthetic Sock, Single Ply, Fitting, Below Knee, Each), L8480 (Prosthetic Sock, Single Ply, Fitting, Above Knee, Each).
Coverage indications, limitations and medical necessity
For any item to be covered by Medicare, it must: 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
Refer to the Supplier Manual for additional information on documentation requirements.
Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
A lower limb prosthesis is covered when the beneficiary:
Will reach or maintain a defined functional state within a reasonable period of time; and
Is motivated to ambulate.
FUNCTIONAL LEVELS:
A determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary’s potential functional abilities. Potential functional ability is based on the reasonable expectations of the treating practitioner and prosthetist, considering factors including, but not limited to:
The beneficiary’s past history (including prior prosthetic use if applicable); and
The beneficiary’s current condition including the status of the residual limb and the nature of other medical problems; and
The beneficiary’s desire to ambulate.
Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels (see the FUNCTIONAL LEVEL CHARACTERISTICS section in the LCD related Policy Article for additional details):
Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.
Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.
Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.
Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.
The medical records must document the beneficiary’s current functional and physical capabilities and their expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.
GENERAL:
If a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not reasonable and necessary.
When an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis (L5510, L5520, L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962, and L5980 which will be denied as not reasonable and necessary. When a below knee preparatory prefabricated prosthesis (L5535) is provided, prosthetic substitutions and/or additions of procedures are covered in accordance with the functional level assessment except for codes L5620, L5629, L5645, L5646, L5670, L5676, L5704, and L5962 which will be denied as not reasonable and necessary.
When an above knee initial prosthesis (L5505) or an above knee preparatory (L5560, L5570, L5580, L5590, L5595, L5600) prosthesis is provided, prosthetic substitution and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5964, L5980, and L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5790, L5795 which will be denied as not reasonable and necessary. When an above knee preparatory prefabricated prosthesis (L5585) is provided, prosthetic substitution and/or additions of procedures and components are covered in accordance with the functional level assessment except for codes L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964, and L5966 which will be denied as not reasonable and necessary.
In the following sections, the determination of coverage for selected prostheses and components with respect to potential functional levels represents the usual case. Exceptions will be considered in an individual case if additional documentation is included which justifies the medical necessity. Prostheses will be denied as not reasonable and necessary if the beneficiary’s potential functional level is 0.
FEET:
A determination of the type of foot for the prosthesis will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the beneficiary. Basic lower extremity prostheses include a SACH foot. Other prosthetic feet are considered for coverage based upon functional classification.
An external keel SACH foot (L5970) or single axis ankle/foot (L5974) is covered for beneficiaries whose functional level is 1 or above.
A flexible-keel foot (L5972) or multiaxial ankle/foot (L5978) is covered for beneficiaries whose functional level is 2 or above.
A microprocessor-controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered when one of the following criteria is met:
The beneficiary’s functional level is 3 or above; or,
The beneficiary's functional level is 2; and,
Meets the functional level 2 coverage criteria for a fluid, pneumatic, or electronic/microprocessor control addition for a prosthetic knee; and,
A higher-level (i.e., functional level 3) foot is required for the safe and proper use of the prescribed knee system.
The microprocessor foot or ankle system addition with power assist which includes any type motor (L5969) is not covered because there is insufficient information to demonstrate that the item meets the Medicare standard to be considered reasonable and necessary as per PIM Chapter 13. Claims for L5969 will be denied as not reasonable and necessary.
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the treating practitioner's or prosthetist's files.
A user-adjustable heel height feature (L5990) will be denied as not reasonable and necessary.
KNEES:
A determination of the type of knee for the prosthesis will be made by the treating practitioner and/or the prosthetist based upon the functional needs of the beneficiary. Basic lower extremity prostheses include a single axis, constant friction knee. Other prosthetic knees are considered for coverage based upon functional classification.
A high activity knee control frame (L5930) is covered for beneficiaries whose functional level is 4.
A fluid or pneumatic knee unit (L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, and L5841), or control addition, fluid (L5848), or electronic/microprocessor (L5856, L5857, L5858) is covered for beneficiaries whose functional level is 3 or above.
A fluid or pneumatic knee unit (L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, and L5841), or control addition, fluid (L5848), or electronic/microprocessor (L5856, L5857, L5858) is also covered under limited circumstances for beneficiaries whose functional level is 2, when all of the following criteria (1-3) are met (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section in the LCD related Policy Article):
The beneficiary has had a clinical evaluation to determine their functional level (see FUNCTIONAL LEVELS section above); and,
Supporting documentation in the medical record outlines, in the context of the beneficiary’s overall medical health, the rationale for selection of a fluid, pneumatic, or electronic/microprocessor-controlled knee, including (at minimum) how the selected knee will:
Improve the beneficiary’s functional health outcomes (e.g., fall reduction, injury prevention, lower energy expenditure); and,
Help the beneficiary accomplish their activities of daily living (ADLs); and,
Lower-level knee systems (e.g., knee systems which exclude use of fluid, pneumatic, or microprocessor) have been considered and ruled out based on the beneficiary’s specific functional and medical needs.
In addition, for coverage of an electronic/microprocessor-controlled knee system (L5856, L5857, or L5858 plus associated components) for beneficiaries whose functional level is 2, all of the following criteria (1-4) must also be met (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section in the LCD related Policy Article):
The electronic/microprocessor knee is indicated for functional level 2; and,
The electronic/microprocessor knee has integrated technology that allows the knee to detect when the user trips or stumbles and can automatically adjust to stabilize the knee unit (e.g., stumble recovery); and,
The beneficiary is able to make use of a product that requires daily charging; and,
The beneficiary is able to understand and respond to error alerts and alarms indicating problems with the function of the unit.
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below:
Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee
K3 functional level only
Has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K3 level function with the use of a microprocessor-controlled knee alone
Is able to make use of a product that requires daily charging
Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit
If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and necessary.
Other knee systems (L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, L5816, L5818) are covered for beneficiaries whose functional level is 1 or above.
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee. This information must be retained in the treating practitioner's or prosthetist's files.
ANKLES:
An axial rotation unit (L5982, L5984, L5985, L5986) is covered for beneficiaries whose functional level is 2 or above.
HIPS:
A pneumatic or hydraulic polycentric hip joint (L5961) is covered for beneficiaries whose functional level is 3 or above.
SOCKETS:
More than 2 test (diagnostic) sockets (L5618, L5620, L5622, L5624, L5626, L5628) for an individual prosthesis are not reasonable and necessary unless there is documentation in the medical record which justifies the need. Exception: A test socket is not reasonable and necessary for an immediate prosthesis (L5400, L5410, L5420, L5430, L5450, L5460).
No more than two of the same socket inserts (L5654, L5655, L5656, L5658, L5661, L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at the same time.
Socket replacements are considered reasonable and necessary if there is adequate documentation of functional and/or physiological need. It is recognized that there are situations where the explanation includes but is not limited to: changes in the residual limb; functional need changes; or irreparable damage or wear/tear due to excessive beneficiary weight or prosthetic demands of very active amputees.
GENERAL
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2026-04-01
- MCD version
- 40
- Derived from
- L27013
Other related documents: A52496 (Article), A55426 (Article), A59857 (Response to Comments).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub and CGS Administrators, LLC hub list every other active policy from the same contractor.
Frequently asked questions
What does LCD L33787 cover?
Will reach or maintain a defined functional state within a reasonable period of time; and The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L33787 apply to?
Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply it to Medicare claims in AK, AL, AR, AS, AZ, CA, CNMI, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L33787?
The current export links no billing and coding article with a diagnosis list to this LCD, so coverage is decided on the indications in the policy text and the documentation in the record rather than by an automated diagnosis edit.
How do I appeal a denial under LCD L33787?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.